New Client Form Please complete and submit the form below. Client Name(Required) First Last Mobile PhoneHome PhoneAddress Street Address Address Line 2 City State ZIP / Postal Code Email(Required) Primary Veterinarian(Required) Pet/Patient Name Breed Color Birthdate/Age Age of pet when acquired Sex(Required) Male Female Spayed/neutered? Yes No Do we have permission to share your pet's picture on our social media?(Required)This may include a short description of the diagnosis, before and after pictures, or just cute pictures! Yes No What problem are you bringing your pet in for?(Required) How long has the problem been present?(Required) How old was your pet when it started?(Required) What did the skin or ear problem initially look like?(Required) How has it changed or spread?(Required) Have the problems been (circle one)(Required) Continual but better on medications Continual even with medications Is the problem worse during certain times of the year?(Required) Yes No If so, when? On a scale of 1 to 10, how itchy is your pet during a typical outbreak?(1 = occasional scratching ~10% of the day, 10 = severe scratching ~100% of the day)Please list ALL medications your pet is currently taking, including supplements and topicals.Does your pet scratch, rub, chew, lick or bite any of the following areas now? Nose Muzzle Eyes Chest Back Paws Back Front Legs Rump Tail Abdomen Back Legs Ears Neck Front Paws Armpits Groin Inner Thighs/Legs What do you feed your pet now? Have any different diets been tried as treatments?Please list the brand name and how long you fed it. How often do you bathe your pet? What flea and tick prevention products are you using for your pet? When was the last dose of flea and tick prevention given? Do any of the other pets or humans in the household have skin issues? Yes No What other pets are in the household? Are there any other symptoms that your pet has that have not been described above? Other than skin disease, does your pet have any other diagnosed medical conditions?
